Preparing for Peritoneal Dialysis

Preparation for home dialysis begins with a robust modality education program because patients cannot make a decision regarding the type of dialysis if they are not provided adequate information. This requires infrastructure that some programs do not have, as well as nephrologists who are welcoming and receptive to their patients' choice of home dialysis. Unfortunately, many dialysis patients in the US do not recall receiving much information about peritoneal dialysis (PD), indicating that the process is often inadequate. This is one barrier to PD. Another is the nephrologist. The nephrologist is the most important influence regarding the decision for PD, so it is critically important that the nephrologist be trained in PD sufficiently to eliminate biases. The program must have the infrastructure to provide robust and comprehensive modality education to patients and their support persons. This includes a one-on-one session with an educator (often a nurse), videos, visits to a home program, peer-to-peer discussion with a PD patient, and follow-up with the nephrologist. Because many patients with advanced chronic kidney disease present urgently with signs and symptoms that require rapid dialysis implementation, an in-house education program is desirable but requires an investment in a nurse educator on site. Once the decision is made to start PD, arrangements are made for PD catheter placement. In most centers, scheduling this procedure can be delayed, so careful planning is necessary. Some innovative programs incorporate interventional nephrologists or radiologists in the program who can place PD catheters and thus ensure that rapid start PD is available. These approaches have been shown to greatly increase PD program size and allow a higher proportion of patients to choose PD at the outset. Use of the buried catheter technique is another approach that may facilitate timely PD start. The home dialysis program must be supported by the dialysis provider or hospital or institution, as appropriate. Adequate staffing is critical to the success of the program, allowing time for training (which is usually one on one), and for meeting the regulations in place for home programs. Space for the home program is also essential, with room for private training and for clinic visits.